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Premalignant Oral Lesions

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Leukoplakia is the most common oral precancer. How common is it according to Bouquot s study??? Leukoplakia: Why is it White? The clinical color (white) ... – PowerPoint PPT presentation

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Title: Premalignant Oral Lesions


1
Premalignant Oral Lesions
  • Precancerous Oral Lesions

2
Precancerous Lesion
  • It is a benign, morphologically altered tissue
    that has a greater than normal risk of malignant
    transformation.
  • Leukoplakia
  • Erythroplakia
  • Erythroleukoplakia

3
Leukoplakia(leuko-white plakia-patch)
  • Oral leukoplakia is defined by the WHO as a
    white patch or plaque that cannot be
    characterized clinically or pathologically as any
    other disease.
  • Thus a diagnosis by exclusion.
  • The term is strictly a CLINICAL one and does not
    imply a specific histopathologic tissue
    alteration.
  • Leukoplakia is the most common oral precancer.
  • How common is it according to Bouquots study???

4
Leukoplakia Why is it White?
  • The clinical color (white) results from a
    thickened surface keratin layer (which appears
    white when wet) or a thickened spinous layer,
    which masks the normal vascularity (redness) of
    the underlying connective tissue.

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Leukoplakia A Premalignant or Precancerous
Lesion
  • Although leukoplakia is not associated with a
    specific histopathologic diagnosis, it is
    considered to be a premalignant lesion for the
    risk of malignant transformation is greater in a
    leukoplakic lesion than that associated with
    normal or unaltered mucosa.

7
Leukoplakia
  • Despite the fact that leukoplakia is a
    premalignant lesion it should be noted that not
    every lesion shows histopathologic evidence of
    epithelial dysplasia or frank malignancy
    (squamous cell carcinoma).
  • In fact, dysplastic epithelium or invasive
    carcinoma is found in only 5 to 25 of the
    biopsy samples of leukoplakia.

8
Leukoplakia Malignant Transformation Potential
  • Overall, the malignant transformation potential
    of leukoplakia is 4 (estimated lifetime risk).
  • However, specific clinical subtypes are
    associated with much high potential malignant
    transformation rates (as high as 47 ).

9
Leukoplakia How Common Is It?
  • Leukoplakia is by far the most common oral
    precancer, accounting for 85 of such lesions.
    (Note this statement is not saying that
    leukoplakia has the highest malignant
    transformation risk of the premalignant group of
    lesions for erythroplakia erythroplasia does).
  • Leukoplakia is also a relatively common lesion
    for it is estimated that approximately 3 of all
    white adults will be affected at some time.
    Additionally, Bouquot in his study of oral
    mucosal lesions found it to be the most common of
    all.

10
Leukoplakia Who Develops It?
  • There is a strong male predilection (70), except
    in parts of the country where females use tobacco
    products more than males.
  • Overall, there has been a slight decrease in the
    proportion of males affected over the past few
    decades.
  • In general, leukoplakia is diagnosed more
    frequently now than in the past, probably because
    of enhance awareness.

11
Leukoplakia Etiology
  • The cause of leukoplakia remains unknown.
  • Over the years the following have been
    considered tobacco, alcohol, sanguinaria,
    ultraviolet radiation, microorganisms and trauma.

12
Etiology of Leukoplakia The Role of Tobacco
  • The habit of tobacco smoking appears most closely
    associated with leukoplakia development.
  • 80 of patients with leukoplakia are smokers.
  • Smokers are much more likely to have leukoplakia
    than non-smokers.
  • Heavier smokers have greater numbers of and
    larger lesions than light smokers.
  • A large proportion of leukoplakias in peresons
    who stop smoking either disappear or become
    smaller soon after discontinuing the habit.

13
Etiology of Leukoplakia The Role of Alcohol and
Sanguinaria
  • Alcohol, which seems to have a strong synergistic
    effect with tobacco in oral cancer development,
    has not been associated with leukoplakia.
  • Sanguinaria (blood root) is a herbal extract that
    has been used in toothpaste and moutwash.
  • Over 80 of the patients with vestibular/maxillar
    y alveolar leukoplakias have a history of using a
    sanguinaria containing product as compared to 3
    of the normal population some lesions have
    persisted after the patient stopped using the
    product.

14
Etiology of Leukoplakia The Role of Ultraviolet
Radiation
  • Ultraviolet radiation has been associated with
    leukoplakia of the vermilion of the lower lip.
  • This leukoplakia is usually associated with
    actinic cheilosis.

15
Etiology of Leukoplakia The Role of
Microorganisms
  • Treponema pallidum has been implicated in
    leukoplakia of the dorsal surface of the tongue
    in patients with syphilis.
  • Candida albicans has been demonstrated
    histologically in the hyperplastic/dysplastic
    epithelium of lesions termed candidal leukoplakia
    and candidal hyperplasia.

16
Etiology of Leukoplakia The Role of
Microorganisms Continued
  • Human papillomavirus (HPV), particularly subtypes
    16 and 18, have been identified in some oral
    leukoplakias.
  • However, HPV has also been demonstrated in normal
    oral epithelial cells.

17
Etiology of Leukoplakia The Role of Trauma
  • Several keratotic lesions, which until recently
    have been viewed as variants of leukoplakia, are
    now considered not to be premalignant.
  • Included in this group are lesions termed
    nicotine stomatitis and frictional keratosis.
  • The keratoses are readily reversible after the
    elimination of the trauma or chronic irritation.

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Leukoplakia Clinical Features
  • Leukoplakia usually affects people over the age
    of 40 years (average age is 60 years).
  • Prevalence increases rapidly with age
    particularly in males.
  • Approximately 8 of the males over the age of 70
    years are reportedly affected.

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Leukoplakia Clinical Features Continued
  • Approximately 70 of the oral leukoplakias are
    found on the lip vermilion, buccal mucosa and
    gingiva.
  • Note Lesions of the tongue, lip vermilion and
    floor of the mouth account for more than 90 of
    those that show dysplasia or carcinoma upon
    histologic examination.

24
Leukoplakia Clinical Features Continued
  • Individual lesions vary in clinical appearance
    and tend to change over time.
  • Early/mild lesions usually appear as slightly
    elevated gray or gray-white plaques, which may
    appear translucent, fissured or wrinkled and are
    typically soft and flat.
  • Early/mild lesions are usually well demarcated
    but may blend into the surrounding normal mucosa.

25
Leukoplakia Clinical Features Continued
  • Early/mild thin leukoplakia, which seldom shows
    dysplasia on biopsy, may disappear or continue
    unchanged.
  • If the cause (s) of the lesion are not removed,
    many lesions will gradually become thicker and
    larger.
  • The clinical appearance (s) of leukoplakia and
    the anticipated underlying histopathologic
    changes are presented in the following diagram.

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Proliferative Verrucous Leukoplakia (PVL)
  • PVL is a special high risk form of leukoplakia.
  • It is characterized by multiple keratotic plaques
    with rough surface projections although initially
    beginning as a simple flat hyperkeratosis.
  • PVL plaques tend to spread slowly, yet
    progressively.
  • PVL usually transforms into a squamous cell
    carcinoma within about 8 years.
  • PVL has a strong female predilection (14 male to
    female) and minimal association with tobacco
    usage.

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Leukoplakia Histopathologic Features
  • Leukoplakia is characterized by a thickened
    keratin layer (hyperkeratosis) with or without a
    thickened spinous layer (acanthosis).
  • Some leukoplakias show surface hyperkeratosis but
    with atrophy or thinning of the underlying
    epithelium.
  • Variable numbers of chronic inflammatory cells
    are typically noted within the underlying
    connective tissue.

34
Leukoplakia Histopathologic Features Continued
  • While most leukoplakias show no dysplasia on
    biopsy, some 5 to 25 of the cases do show
    evidence of epithelial dysplasia (or squamous
    cell carcinoma).
  • The histopathologic alterations of dysplastic
    epithelial cells are outlined in the next slide.

35
Histopathologic Alterations of Dysplastic
Epithelial Cells
  • Enlarged nuclei and cells.
  • Large and prominent nucleoli.
  • Increased nuclear-cytoplasmic ratio.
  • Hyperchromatic (dark-staining) nuclei.
  • Pleomorphic (abnormally shaped) nuclei and cells.
  • Dyskeratosis (premature keratinization)
  • Increased mitotic activity and abnormal mitotic
    figures

36
Histopathologic Alterations of Dysplastic
Epithelium Continued
  • Bulbous or teardrop-shaped rete ridges.
  • Loss of polarity (lack of progressive maturation
    toward the surface).
  • Keratin or epithelial pearls.
  • Loss of typical epithelial cell cohesiveness.

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Leukoplakia Treatment and Prognosis
  • Leukoplakia represents a clinical diagnosis and
    therefore the first step in treatment is to
    arrive at a definitive diagnosis via biopsy and
    histologic examination of the tissue.
  • Treatment depends upon the diagnosis and any
    leukoplakia exhibiting moderate epithelial
    dysplasia or worse warrants complete removal if
    possible. Treatment of lesions exhibiting less
    severe changes is guided by the size of the
    lesion and its response to more conservative
    measures such as eliminating tobacco use.

45
Leukoplakia Treatment and Prognosis Continued
  • Leukoplakia not exhibiting dysplasia often is not
    excised but clinical evaluation every 6 months is
    recommended.
  • Additional biopsies are recommended if smoking
    continues or if clinical changes increase in
    severity.
  • The following diagram represents the various
    clinical appearance of oral leukoplakia and the
    anticipated underlying associated histopathologic
    changes.

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Leukoplakia Treatment and Prognosis Continued
  • Complete removal of oral leukoplakia can be
    accomplished with equal effectiveness by surgical
    excision, electrocautery, cryosurgery or laser
    ablation.
  • Long-term follow-up after removal is mandatory
    because of recurrence potential and because new
    leukoplakias may occur.
  • Malignant transformation potential is related to
    clinical appearance and the degree of dysplasia
    present.

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Erythroplakia Definition
  • Erythroplakia is defined as a red patch that
    cannot be clinically or pathologically diagnosed
    as any other condition.
  • Erythroplasia is occasionally used as a synonym
    for erythroplakia although it was originally used
    by Queyrat to describe a precancerous red lesion
    of the penis.

50
Erythroplakia
  • Almost all true erythroplakias demonstrate
    significant epithelial dysplasia, carcinoma in
    situ or invasive squamous cell carcinoma.
  • The cause (s) of erythroplakias are unknown but
    presumed to be the same as those associated with
    squamous cell carcinoma.

51
Erythroplakia
  • Erythroplakia is far less common than leukoplakia
    but has a much greater potential to be severely
    dysplastic at the time of biopsy or to develop
    invasive malignancy at a later time.
  • Erythroplakia can occur in conjunction with
    leukoplakia and has been found concurrently with
    a large proportion of early invasive oral
    carcinomas.

52
Erythoplakia Clinical Features
  • It is predominantly a disease of older males with
    a peak prevalence between the ages of 65 and 74
    years.
  • The floor of the mouth, tongue and soft palate
    are the most commonly involved sites.
  • Multiple lesions may occur.
  • Early erythroplakias appear as well-demarcated
    erythematous macules or plaques with a soft
    velvety texture.
  • Unfortunately, it is usually asymptomatic.

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Erythroplakia Histopathologic Features
  • Approximately 90 of these lesions represent
    either severe epithelial dysplasia, carcinoma in
    situ, or superficially invasive carcinoma.
  • Typically the epithelium shows a lack of keratin
    production and is often atrophic.
  • This lack of keratinization, coupled with
    epithelial thinness allows the underlying
    microvasculature to show through imparting the
    red appearance.

57
Erythroplakia Treatment and Prognosis
  • As with leukoplakia, the treatment is guided by
    the definitive diagnosis obtained by biopsy.
  • Lesions exhibiting moderate dysplasia or worse
    must be completely removed.
  • Recurrence and multifocal oral mucosal
    involvement necessitates long-term follow-up.

58
Erythroleukoplakia
  • This term is used for lesions that have both a
    red (Erythroplakia) and white (Leukoplakia)
    component.
  • Formerly called either speckled erythroplakia or
    speckled leukoplakia depending upon which (red or
    white) accounted for the majority component.

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Precancerous Oral Conditions
  • A precancerous condition is a disease or patient
    habit that does not necessarily alter the
    clinical appearance of the local tissue but is
    associated with a greater than normal risk of a
    precancerous lesion or cancer developing in that
    tissue.

62
Plummer-Vinson Syndrome(Paterson-Kelly Syndrome)
  • This is an uncommon condition characterized by an
    iron-deficiency anemia with an associated
    glossitis and dysphagia.
  • It is of significance because of its association
    with a high frequency of oral and esophageal
    squamous cell carcinoma.

63
Plummer-Vinson Syndrome Clinical Features
  • This syndrome is most common in females between
    the ages of 30 and 50 years.
  • It is more common in patients of Scandinavian and
    northern European background.
  • Patients complain of a burning tongue/mouth.
  • Angular cheilitis and a smooth red tongue are
    often presenting features.
  • Dysplasia (difficulty) or pain on swallowing are
    often manifestations of esophageal webs (abnormal
    tissue bands in the esophagus).

64
Plummer-Vinson Syndrome Clinical Features
Continued
  • Another sign involves the nails, which are often
    spoon-shaped (koilonychia) and may be brittle.
  • The symptoms of anemia such as fatigue, shortness
    of breath and weakness often lead the patient to
    seek medical care.

65
Plummer-Vinson Syndrome Laboratory
Microscopic Features
  • Hematologic studies show a hypochromic,
    microcytic anemia consistent with iron-deficiency
    anemia.
  • Biopsy of the oral mucosa reveals epithelial
    atrophy with submucosal inflammation.
  • In advanced case one may see epithelial atypia,
    dysplasia, carcinoma in situ or frank squamous
    cell carcinoma.

66
Plummer-Vinson Syndrome Treatment and Prognosis
  • Treatment centers on correcting the
    iron-deficiency anemia and if this is successful,
    the glossodynia and esophageal symptoms improve.
  • Patients should be evaluated periodically for
    oral, pharyngeal and esophageal cancer.
  • The frequency of malignancy in these patients has
    ranged from 5 to 50 in the literature.

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Oral Submucous Fibrosis Clinical Features
  • Oral lesions appear as areas of opacification
    with loss of elasticity.
  • Fibrous bands may occur.
  • Any region of the oral cavity may be affected.

71
Oral Submucous Fibrosis Cause
  • This lesion may be a result of a hypersensitivity
    reaction to dietary constituents such as betel
    nut, capsaicin, etc.

72
Oral Submucous Fibrosis Treatment
  • No treatment has been consistently effective.
  • Intralesional corticosteroids, surgical splitting
    or excision of the fibrous band have been helpful
    in some cases.

73
Oral Submucous Fibrosis Significance
  • The greatest significance is that oral submucous
    fibrosis is a high-risk precancerous condition.
  • Additionally, these fibrous lesions are not
    reversible restricting many oral movements.

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